bill barring health plans from refusing first responders’ on-the-job injuries

The text as introduced · 1,048 words

89R10050 DNC-D

By: Martinez
H.B. No. 3914

A BILL TO BE ENTITLED

AN ACT

relating to the health benefit plan coverage of and reimbursement

for the treatment of a first responder's injuries sustained within

the course and scope of employment.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subtitle E, Title 8, Insurance Code, is amended

by adding Chapter 1373 to read as follows:

CHAPTER 1373. COVERAGE FOR WORK-RELATED INJURIES

Sec. 1373.001. DEFINITIONS. In this chapter:

(1) "First responder" means:

(A) an individual employed by a political

subdivision of this state who is:

(i) a peace officer under Article 2A.001,

Code of Criminal Procedure;

(ii) a person licensed under Chapter 773,

Health and Safety Code, as an emergency care attendant, emergency

medical technician, emergency medical technician-intermediate,

emergency medical technician-paramedic, or licensed paramedic; or

(iii) a firefighter subject to

certification by the Texas Commission on Fire Protection under

Chapter 419, Government Code, whose principal duties are

firefighting and aircraft crash and rescue; or

(B) an individual covered under Section

504.012(a), Labor Code, who is providing volunteer services to a

political subdivision of this state as:

(i) a volunteer firefighter, without regard

to whether the volunteer firefighter is certified under Subchapter

D, Chapter 419, Government Code; or

(ii) an emergency medical services

volunteer, as defined by Section 773.003, Health and Safety Code.

(2) "Workers' compensation insurance carrier" means an

insurance carrier, as that term is defined by Section 401.011,

Labor Code.

Sec. 1373.002. APPLICABILITY. (a) This chapter applies

only to a health benefit plan that provides benefits for medical or

surgical expenses incurred as a result of a health condition,

accident, or sickness, including an individual, group, blanket, or

franchise insurance policy or insurance agreement, a group hospital

service contract, or an individual or group evidence of coverage or

similar coverage document that is issued by:

(1) an insurance company;

(2) a group hospital service corporation operating

under Chapter 842;

(3) a health maintenance organization operating under

Chapter 843;

(4) an approved nonprofit health corporation that

holds a certificate of authority under Chapter 844;

(5) a multiple employer welfare arrangement that holds

a certificate of authority under Chapter 846;

(6) a stipulated premium company operating under

Chapter 884;

(7) a fraternal benefit society operating under

Chapter 885;

(8) a Lloyd's plan operating under Chapter 941; or

(9) an exchange operating under Chapter 942.

(b) Notwithstanding any other law, this chapter applies to:

(1) a primary care coverage plan under Chapter 1579;

(2) county employee group health benefits provided

under Chapter 157, Local Government Code; and

(3) health and accident coverage provided by a risk

pool created under Chapter 172, Local Government Code.

(c) Section 1425.001(a)(6) does not limit the applicability

of this chapter.

Sec. 1373.003. COVERAGE REQUIRED. (a) A health benefit

plan that provides coverage for a first responder may not exclude

coverage of the first responder's claim for medical benefits for

treatment of an injury, including all health care required to cure

or relieve the effects naturally resulting from the injury, because

the injury was or may have been sustained in the course and scope of

employment as a first responder or because the injury is or might be

compensable under workers' compensation insurance coverage.

(b) For purposes of this chapter, an injury sustained in the

course and scope of employment includes an injury sustained by a

first responder providing services on a volunteer basis.

Sec. 1373.004. REIMBURSEMENT OF CLAIM. (a) A first

responder whose claim for workers' compensation medical benefits is

denied by the workers' compensation insurance carrier shall provide

the health care provider treating the injury with proof of the

initial denial.

(b) A health benefit plan issuer shall pay the health care

provider the allowed amount under the health benefit plan for

services provided to treat the injury, regardless of whether the

injury is ultimately determined to be a compensable injury for

purposes of the first responder's workers' compensation insurance

coverage.

(c) If the workers' compensation insurance carrier, after

the initial denial, accepts the workers' compensation claim for the

injury, the carrier shall:

(1) completely reimburse the health benefit plan for

any amounts paid to a provider for the treatment of the injury; and

(2) reimburse the injured first responder for any

copayment or deductible that was paid in connection with treatment

for the injury.

SECTION 2. Section 409.0091, Labor Code, is amended by

amending Subsection (h) and adding Subsection (h-1) to read as

follows:

(h) Except as otherwise provided by Subsection (h-1), for

[ For ] each medical benefit paid, the workers' compensation

insurance carrier shall pay to the health care insurer the lesser of

the amount payable under the applicable fee guideline as of the date

of service or the actual amount paid by the health care insurer. In

the absence of a fee guideline for a specific service paid, the

amount per service paid by the health care insurer shall be

considered in determining a fair and reasonable payment under rules

under this subtitle defining fair and reasonable medical

reimbursement. The health care insurer may not recover interest as

a part of the subclaim.

(h-1) The workers' compensation insurance carrier shall

reimburse a health care insurer for the actual amount paid by the

health care insurer to a health care provider for the treatment of

an injured first responder under Section 1373.003, Insurance Code.

SECTION 3. (a) The division of worker's compensation of the

Department of Insurance shall conduct a study regarding the impact

of the changes in law made by this Act. The study must include an

assessment of:

(1) the efficiency with which health benefit plans

provide medical care for injured first responders while awaiting

resolution of workers' compensation claims;

(2) the geographic areas where the coverage was

successful; and

(3) the health benefit plans that provided coverage to

an injured first responder.

(b) Not later than December 1, 2028, the division shall

submit to the legislature a written report that includes a summary

of the study and any legislative recommendations based on the

study.

SECTION 4. Chapter 1373, Insurance Code, as added by this

Act, applies only to a health benefit plan that is delivered, issued

for delivery, or renewed on or after January 1, 2026.

SECTION 5. This Act takes effect September 1, 2025.